Subscribe to RSS
![](/products/assets/desktop/img/oa-logo.png)
DOI: 10.1055/s-0035-1554932
Histoplasmosis with Deep CNS Involvement: Case Presentation with Discussion and Literature Review
Publication History
09 December 2014
06 April 2015
Publication Date:
26 June 2015 (online)
![](https://www.thieme-connect.de/media/jnlsr/201501/lookinside/thumbnails/10-1055-s-0035-1554932_140114-1.jpg)
Abstract
Central nervous system (CNS) histoplasmosis is rare and difficult to diagnose because it is often overlooked or mistaken for other pathologies due to its nonspecific symptoms. A 32-year-old Hispanic man with advanced acquired immunodeficiency virus presented with altered mental status and reported confusion for the past 3 months. He had a Glasgow Coma Scale of 12, repetitive nonfluent speech, and a disconjugate gaze with a right gaze preference. Lung computed tomography (CT) findings indicated a pulmonary histoplasmosis infection. Magnetic resonance imaging of the brain revealed a ring-enhancing lesion in the left caudate nucleus. A CT-guided left retroperitoneal node biopsy was performed and indicated a benign inflammatory process with organisms compatible with fungal yeast. Treatment with amphotericin B followed by itraconazole was initiated in spite of negative cerebrospinal fluid (CSF) cultures and proved effective in mitigating associated CNS lesions and resolving neurologic deficits. The patient was discharged 3 weeks later in stable condition. Six weeks later, his left basal ganglia mass decreased. Early recognition of symptoms and proper steps is key in improving outcomes of CNS histoplasmosis. Aggressive medical management is possible in the treatment of intracranial deep mass lesions, and disseminated histoplasmosis with CNS involvement can be appropriately diagnosed and treated, despite negative CSF and serology studies.
-
References
- 1 Kauffman CA. Histoplasmosis: a clinical and laboratory update. Clin Microbiol Rev 2007; 20 (1) 115-132
- 2 Eissenberg LG, Goldman WE, Schlesinger PH. Histoplasma capsulatum modulates the acidification of phagolysosomes. J Exp Med 1993; 177 (6) 1605-1611
- 3 Sebghati TS, Engle JT, Goldman WE. Intracellular parasitism by Histoplasma capsulatum: fungal virulence and calcium dependence. Science 2000; 290 (5495) 1368-1372
- 4 Trofa D, Nosanchuk JD. Histoplasmosis of the central nervous system. J Neuroparasitology 2012; 3: 1-7
- 5 Veeravagu A, Ludwig C, Camara-Quintana JQ, Jiang B, Lad N, Shuer L. Fungal infection of a ventriculoperitoneal shunt: histoplasmosis diagnosis and treatment. World Neurosurg 2013; 80 (1-2) 222.e5-222.e13
- 6 Goldman M, Zackin R, Fichtenbaum CJ , et al; AIDS Clinical Trials Group A5038 Study Group. Safety of discontinuation of maintenance therapy for disseminated histoplasmosis after immunologic response to antiretroviral therapy. Clin Infect Dis 2004; 38 (10) 1485-1489
- 7 McKinsey DS, Spiegel RA, Hutwagner L , et al. Prospective study of histoplasmosis in patients infected with human immunodeficiency virus: incidence, risk factors, and pathophysiology. Clin Infect Dis 1997; 24 (6) 1195-1203
- 8 Wheat LJ, Musial CE, Jenny-Avital E. Diagnosis and management of central nervous system histoplasmosis. Clin Infect Dis 2005; 40 (6) 844-852
- 9 Black KE, Baden LR. Fungal infections of the CNS: treatment strategies for the immunocompromised patient. CNS Drugs 2007; 21 (4) 293-318
- 10 Saccente M. Central nervous system histoplasmosis. Curr Treat Options Neurol 2008; 10 (3) 161-167
- 11 Carod-Artal F, Venturini M, Gomes E, de Mello M. Chronic central nervous system histoplasmosis in an immunocompetent patient [in Spanish]. Neurologia 2008; 23 (4) 263-268
- 12 Hamada M, Tsuji S. Central nervous system histoplasmosis [in Japanese]. Brain Nerve 2009; 61 (2) 129-134
- 13 Vullo V, Mastroianni CM, Ferone U , et al. Central nervous system involvement as a relapse of disseminated histoplasmosis in an Italian AIDS patient. J Infect 1997; 35 (1) 83-84
- 14 Guarner J, Brandt ME. Histopathologic diagnosis of fungal infections in the 21st century. Clin Microbiol Rev 2011; 24 (2) 247-280
- 15 Aravalli RN, Hu S, Woods JP, Lokensgard JR. Histoplasma capsulatum yeast phase-specific protein Yps3p induces Toll-like receptor 2 signaling. J Neuroinflammation 2008; 5: 30
- 16 Khasawneh FA, Ahmed S, Halloush RA. Progressive disseminated histoplasmosis presenting with cachexia and hypercalcemia. Int J Gen Med 2013; 6: 79-83
- 17 Nguyen FN, Kar JK, Zakaria A, Schiess MC. Isolated central nervous system histoplasmosis presenting with ischemic pontine stroke and meningitis in an immune-competent patient. JAMA Neurol 2013; 70 (5) 638-641
- 18 Ramireddy S, Wanger A, Ostrosky L. An instructive case of CNS histoplasmosis in an immunocompetent host. Med Mycol Case Rep 2012; 1 (1) 69-71
- 19 Cleary JD, Pearson M, Oliver J, Chapman SW. Association between Histoplasma exposure and stroke. J Stroke Cerebrovasc Dis 2008; 17 (5) 312-319
- 20 Paphitou NI, Barnett BJ. Solitary parietal lobe histoplasmoma mimicking a brain tumor. Scand J Infect Dis 2002; 34 (3) 229-232
- 21 Loughan AR, Perna R, Hertza J. Cognitive impairment and memory loss associated with histoplasmosis: a case study. Clin Neuropsychol 2014; 28 (3) 514-524
- 22 Shapiro JL, Lux JJ, Sprofkin BE. Histoplasmosis of the central nervous system. Am J Pathol 1955; 31 (2) 319-335
- 23 Azizirad O, Clifford DB, Groger RK, Prelutsky D, Schmidt RE. Histoplasmoma: isolated central nervous system infection with Histoplasma capsulatum in a patient with AIDS. Case report and brief review of the literature. Clin Neurol Neurosurg 2007; 109 (2) 176-181
- 24 Hott JS, Horn E, Sonntag VKH, Coons SW, Shetter A. Intramedullary histoplasmosis spinal cord abscess in a nonendemic region: case report and review of the literature. J Spinal Disord Tech 2003; 16 (2) 212-215
- 25 John AM, Vasanthi N, Khurana A , et al. An unusual cause for rings in the brain. Hong Kong Med J 2012; 18 (4) 346-347
- 26 Klein CJ, Dinapoli RP, Temesgen Z, Meyer FB. Central nervous system histoplasmosis mimicking a brain tumor: difficulties in diagnosis and treatment. Mayo Clin Proc 1999; 74 (8) 803-807
- 27 Murata M, Furusyo N, Otaguro S, Nabeshima S, Ariyama I, Hayashi J. HIV infection with concomitant cerebral toxoplasmosis and disseminated histoplasmosis in a 45-year-old man. J Infect Chemother 2007; 13 (1) 51-55
- 28 Parihar A, Tomar V, Ojha BK, Husain N, Gupta RK. Magnetic resonance imaging findings in a patient with isolated histoplasma brain abscess. Arch Neurol 2011; 68 (4) 534-535
- 29 Saccente M, McDonnell RW, Baddour LM, Mathis MJ, Bradsher RW. Cerebral histoplasmosis in the azole era: report of four cases and review. South Med J 2003; 96 (4) 410-416
- 30 Smith JS, Quiñones-Hinojosa A, Phillips JJ, Bollen AW, McDermott MW, Cha S. Limitations of diffusion-weighted imaging in distinguishing between a brain tumor and a central nervous system histoplasmoma. J Neurooncol 2006; 79 (2) 217-218
- 31 Kastrup O, Wanke I, Maschke M. Neuroimaging of infections. NeuroRx 2005; 2 (2) 324-332
- 32 Rangel-Castilla L, Hwang SW, White AC, Zhang YJ. Neuroendoscopic diagnosis of central nervous system histoplasmosis with basilar arachnoiditis. World Neurosurg 2012; 77 (2) E9-E13
- 33 Wheat LJ, Connolly P, Smedema M , et al. Activity of newer triazoles against Histoplasma capsulatum from patients with AIDS who failed fluconazole. J Antimicrob Chemother 2006; 57 (6) 1235-1239
- 34 Wheat LJ, Freifeld AG, Kleiman MB , et al; Infectious Diseases Society of America. Clinical practice guidelines for the management of patients with histoplasmosis: 2007 update by the Infectious Diseases Society of America. Clin Infect Dis 2007; 45 (7) 807-825